Should I write the same way I speak?
No.
Written and spoken English are different dialects of
the English language. Yes, both are still English, but what works well for
one is not necessarily work well for the other.
This applies to writing in general, and also applies to
writing a medical chart.
Some examples of the differences between spoken and
written English are in the lists below.
|
Spoken
|
Written
|
|
Tone
|
No equivalent
|
|
Timing
|
Uses punctuation instead
|
|
Rhythm
|
Uses punctuation instead
|
|
Inflection
|
No equivalent
|
|
Volume
|
No equivalent
|
Imagine reading a move script in your mind vs hearing it
read out loud by good actors. It’s a world of difference. Spoken language is
rich with other cues beyond the words themselves.
Good writing is not necessarily good speaking and vice
versa. Good writing is typically more brief, terse, and direct. When
reading good writing out loud, a listener may not catch every idea in a
sentence in written English simply because of the brevity. The extra words
themselves can give your listener an extra moment to process what you’re
saying. When a reader is looking at the words on paper, these extra words are
not necessary. In fact, the extra words get in the way.
Let’s look at these examples:
Spoken
I
did read the CT scan of the chest. It showed no pulmonary embolism, but did
show a left lower lobe pneumonia.
Written
CT
read showed left lower lobe pneumonia. No PE.
The written version is shorter, and more compact. Writing
allows the use of abbreviations and acronyms to make it more compact. When
spoken out loud, the shorter sentence gives the listener less time to process
the information.
Writing is refined thinking. The writer has to consider
what words to use, and how to place the words in an efficient, coherent way.
More mental processing goes into writing than goes into speaking. Speaking is
natural. Writing is not. Writing gives you more opportunity to refine the end
product than speaking, because you have to think more when you write
A good example of this is a dictated chart. When you do
not take the conscious step of extra editing, your dictated chart will tend to
ramble. It can look like a stream of consciousness. This is bad written communication.
It’s much more difficult to read and understand.
You are also more likely to say accidentally something
that you don’t intend to say.
Spoken (I dictated this to myself without editing)
The
patient is a 25 year old female with a medical history of asthma. She came into
the ER with accessory muscle use, shortness of breath, wheezing and said that
this was consistent with asthma attacks she had in the past. She denied recent steroid
use, and previous ICU admission. However, she said that she had a admission for
asthma about 6 months ago. Her last steroid use was about 2 months ago, that
she received from her primary doctor. Preceding symptoms include uri symptoms
such as runny nose, sneezing, and dry cough. Overall, she had the asthma symptoms
for about 2 days that are gradually worsening and the preceding uri syptoms for
about 2 days as well.
Written
25
year old female asthmatic. She came into the ER with 2 days of symptoms consistent
with asthma attack, including accessory muscle use, shortness of breath, and wheezing.
No recent steroid use, or previous ICU admission. Most recent admission for
asthma about was 6 months ago. Most recent steroid use about 2 months ago.
Preceding symptoms include 2 days of runny nose, sneezing, and dry cough.
The written version is more compact, direct, better
organized, easier read, and overall better communication. The directly
transcribed spoken version comes across as a rambling, scattered stream of consciousness.
The directly transcribed, spoken is worse communication by far.
If you’re going to use dictation, be sure that you put
some thought into the words you are dictating. You should take the extra step
and edit your words (either mentally or on the computer screen). You are
translating from one dialect into another. Take the extra mental steps for
that translation before you speak so that your charts aren’t rambling. Use the
words in your mind and craft them in a way that is efficient.
If you are working with a scribe, make sure that the
scribe knows that they should not transcribe word for word unless you are going
to heavily edit the chart later. The scribe has to translate from spoken
English to written English.
Either way remember to take the perspective of the
reader. What will be easier for them to understand? Take these concepts
into account and your dictations will get better.
To learn more about effective medical charting, check out
my Handbook
of Medical Charting
